Sunday, January 22, 2006

Defending scientific medicine

I have blogged critically about alternative medicine. This post is driven by readers’ comments. They follow several general themes to which I offer this response.

They laughed when researchers claimed a bacterial infection could cause ulcers. Those researchers just won the Nobel Prize.Several readers made this point after I criticized “research” that was not based on biologic plausibility. This premise, that the mainstream rejected the bacterial theory, is false. A Pub Med search yields a spate of favorable articles within several years of the 1983 Helicobacter paper. There’s a distinction to be made. The notion of a bacterial cause of peptic ulcer was novel but not implausible. Furthermore it had an evidentiary basis. (Those researchers could actually look in the microscope and see the critters inhabiting the stomach lining). Contrast that with homeopathy---the idea that once all molecules are diluted out of solution a force is left behind which imparts clinical effects. I would be the first to urge research funding for homeopathy if there was even a shred of evidence that such a force exists. If it’s powerful enough to cure multiple ailments why hasn’t it been measured in the more than 200 years since Samuel Hahnemann advanced the theory? Wouldn’t it alter the physical properties of water in some way---maybe alter the electrostatic charges or the hydrogen bond configuration? I think the folks at MIT would have demonstrated something by now.

Mainstream medicine ignores the psychosocial dimensions of health and disease.Moof said it well: “I think that the reason the general public is so keen on that sort of thing is because the pseudo-scientific 'medicines' are more in the business of connecting with people on an emotive level than they are on a medical level. To counter this, serious medicine may have to try a bit harder to relate to more than just the physical aspects of illnesses.” Although a scientific underpinning doesn’t preclude an emotional connection doctors, for a variety or reasons, don’t spend enough time with patients. The unfortunate consequence is that alternative practitioners have hijacked the concept of “treating the whole person.”

Mainstream medicine doesn’t have all the answers.Of course not. Tune up your baloney detector and run from any medical system that claims to have all the answers.

Mainstream medicine is just following the money.That’s partially true, and maybe it’s why the mainstream increasingly embraces quackery. It sells.

If patients think it works, what’s the harm?Patients have the right to choose. They are and should be free to go to the local herbalist or purchase the latest colon cleanse remedy. It’s quite another thing for us in the mainstream to endorse invalid methods. We claim to base our practices on good science and that’s what the public expects of us. If we accommodate unscientific practices through some sort of “integration” we endorse those practices, either explicitly or implicitly. Our science then becomes pretense. That’s pseudoscience. It betrays the public’s expectation and is, in my opinion, unethical.

But medicine is NOT scientific. What's the figure you hear--15% of what doctors do is evidence based. The rest is just doctors doing what they always have done--like quoting Galen by rote.

I recently went to doctor and he prescribed some medicine for my condition. I asked him whether he was prescribing off label and if so what studies support his belief that the drug was effective on my condition. He said there was none; it just "worked in his experience"

Hmmm . . . well, I imagine the doctors of the 17th century were convinced that bleeding "worked in their experience." Confirmation bias--let alone the legal and economic need of professions to reify knowledge and claim authority even if none exist--create such sureness. But experience is not knowledge.

Medicine is not science; patients should not be automatically deferential to doctor's experience. If alternative approaches work for them, more power to them.

Anonymous,Thank you for your comment. It's true that medicine is not always scientific, but I disagree with your figure of 15%. The best evidence suggests that figure is closer to 50%. Seehttp://content.nejm.org/cgi/content/abstract/348/26/2635

Of course, 50% is not so hot. That's what the proponents of evidence based medicine are trying to fix.

I'm not defending mainstream medicine; I'm calling for medicine to be more faithful to its purported scientific underpinning. Granted they do a poor job of aligning their practices with what the science says. They need to do better. But the last thing they need to do to fix the problem is to introduce more psuedoscience, more myth, more dogma than is already there.